Malawi takes on cholera outbreak amid cyclone devastation
Authors: Sanjeet Bagcchi
Journal: The Lancet Microbe (2022)

On March 3, 2022, an outbreak of cholera in Malawi was declared by the Malawian Ministry of Health. As of April 26, four deaths and 78 cases had been reported to WHO, contributing to an estimated case fatality ratio of 5·1%. According to WHO, people from southern Malawi, who were displaced due to torrential rains and floods during late January to February 2022, did not have access to safe drinking water and sanitation services and, therefore, were at an increased risk of diseases such as cholera. The announcement by the Ministry of Health came after a cholera diagnosis was confirmed by laboratory results in a man aged 57 years who was residing in the Machinga district and had watery diarrhoea since Feb 28, 2022. Vibrio cholerae O1 serotype Inaba was isolated from the patient. The second case in the outbreak was reported on March 7, 2022, in a boy aged 11 years from the Nsanje district. Overall, the 78 cases were reported from individuals aged 2–57 years; however, the most affected age group was children and adolescents aged 5–14 years. 76 (97%) cases were from the Nsanje district and two from the Machinga district (3%), both regions in the south of Malawi. Malawi is currently addressing the aftermath of cyclone Ana (Jan 28, 2022) and cyclone Gombe (March 11–13, 2022), which collectively killed 51 people and are estimated to have impacted over 1 million people. Janet Kayita (Acting WHO Representative, WHO, Lilongwe, Malawi), told The Lancet Microbe that the torrential rains and flooding caused by cyclone Ana, extensive damage to water and sanitation systems, and overcrowding created the perfect conditions for a cholera outbreak—a risk that was outlined in the Malawi National Emergency Response in January, 2022. “Although a preparedness plan existed, it was not matched with the requisite system capacities,” she said. The World Bank, which describes Malawi as one of the poorest countries in the world, projects that economic growth will slow substantatially as a result of these adverse weather conditions. Between 1998 and 2020 Malawi experienced seasonal outbreaks of cholera, and the bacterial disease is endemic in the country with southern region known as a hotspot for these recurrent outbreaks. However, “cholera in Malawi is not inevitable”, says Kayita, who believes that Malawi's success in tackling other public health emergencies, such as the wild poliovirus type 1 outbreak in February, 2022, shows that Malawi has “several strengths that are critical to the control and elimination of cholera”. According to Kayita, one of these strengths is the “government ownership and leadership” that has “enabled the nationwide mobilisation of a range of multisectoral actors behind one common agenda”. The agenda to tackle the cholera outbreak in Malawi was outlined in the National Cholera Response Plan, put forward by the Malawian government in collaboration with WHO and other partners, including UNICEF, as a public health response following the beginning (March 2022) of the outbreak. The plan involved strengthening water, sanitation, and hygiene (WASH) services, vaccinating people with oral cholera vaccine (OCV), and promoting cholera awareness campaigns in communities. Alongside suitable treatment of cases and boosting surveillance at community level, WHO also called for improvements in access to clean water and sanitation services, waste treatment, and food safety and hygiene practices. To support the National Cholera Response Plan, Global Emergency Stockpile provided Malawi with 1·9 million doses of OCV in April 2022, which the country started to rollout to adults and children (aged 1 year and older) who reside in flood-affected areas in May 2022. The vaccine, which requires a schedule of two doses administered 2 weeks apart, has been approved for emergency use in eight high-risk districts. This multisectoral approach and vaccine rollout was praised by Lauren D’Mello-Guyett, (London School of Hygiene & Tropical Medicine, London, UK) who told The Lancet Microbe: “the combination of the 1·9 million doses of OCV and targeted community WASH interventions may be able to contain and control the outbreak”. Despite the coordinated effort, surveillance will be needed as the outbreak continues, particularly as Malawi borders three countries. “[The] flooding in the southern region [of Malawi] has created conditions ripe for cholera spread and the situation is indeed cause for concern,” said Andrew Azman (Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA). According to Azman, many cases of cholera in Malawi to date have come from Mozambique, which shares a border with the high-risk southern districts of Malawi. A coordinated cross-border response will likely be important in controlling any further spread of cholera in the region. For more on cholera in Malawi see https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON372For more on cyclones Ana and Gombe in Malawi see https://apps.who.int/iris/bitstream/handle/10665/353351/OEW16-1111720422022.pdfFor more on the economy in Malawi see https://www.worldbank.org/en/country/malawi/overview#1For more on the oral cholera vaccine rollout in Malawi see https://www.afro.who.int/countries/malawi/news/malawi-receives-19-million-doses-cholera-vaccines-strengthen-cholera-preparedness-and-response For more on cholera in Malawi see https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON372 For more on cyclones Ana and Gombe in Malawi see https://apps.who.int/iris/bitstream/handle/10665/353351/OEW16-1111720422022.pdf For more on the economy in Malawi see https://www.worldbank.org/en/country/malawi/overview#1 For more on the oral cholera vaccine rollout in Malawi see https://www.afro.who.int/countries/malawi/news/malawi-receives-19-million-doses-cholera-vaccines-strengthen-cholera-preparedness-and-response